Patients with obvious deformity should be urgently reduced in the ED. Reduction is accomplished (with analgesia ± conscious sedation) by gentle longitudinal traction and replacement of the talus under the tibia, followed by immediate splinting in gentle internal rotation to maintain reduction.  Many of these unstable fractures will require operative fixation, so early communication with the orthopedist is important.

      Isolated lateral malleolus fractures distal to the syndesmosis with no clinical or radiographic evidence of ankle instability may be treated with splinting in either a short-leg cast or posterior mold splint (there is no clear consensus). These patients should be non-weight bearing until seen by an orthopedist for follow-up within the first week.  They typically require 6 to 8 weeks of casting. Fractures at or proximal to the syndesmosis and with medial injury are more commonly associated with ankle instability and require prompt follow-up with similar splinting and non-weightbearing status.